Setting

Patients

2763 postmenopausal women <80 years of age (mean age 67 y, 89% white) with established CAD but no previous venous thromboembolism
and who had not had a hysterectomy. Exclusion criteria were CAD event ≤6 months or hormone use ≤3 months before entry, venous
thromboembolism, breast cancer, endometrial cancer, uncontrolled hypertension, diabetes, or other fatal disease. Follow up
was 98%.

Commentary

Controversy continues over the nature and extent of the risks of hormone therapy in women, whether used as an oral contraceptive
or HRT. The differences of scientific opinion, however, as to the risks and benefits of hormone therapies, arise largely from
the difficulty in interpreting studies that are limited by methodological problems.

This well designed, randomised, triple blind, placebo controlled trial by Grady et al provides convincing evidence that women with established CAD who take HRT (specifically oestrogen plus progestin) after menopause
have an increased risk of venous thromboembolic disease. At a mean follow up of 3.3 years, the investigators notified participants
to discontinue study medications in situations associated with increased risk for venous thromboembolism, such as surgery,
admission to hospital, fracture, and cancer. Among women in the study, treating 66 women with CAD for 1 year would result
in 1 additional venous thromboembolic event. The findings confirm those of previous studies, concluding that the increased
risk was most likely related to the oestrogen component of hormone therapy.1

This study supports women's health advocates who, over the past 50 years, have cautioned women of all ages against indiscriminate
use of hormone therapy.2 Health practitioners are therefore challenged to weigh the benefits and risks when advising postmenopausal women with CAD
about the use of HRT. It is clear from this study that women with any risk factors (eg, cancer, cardiovascular disease, lower
extremity fracture, or immobilisation for any reason) should not take HRT. If a woman decides that the benefits outweigh the
risks, then she needs to be advised on how to prevent thromboembolic disease (eg, increasing mobility). Health practitioners
and women also need to be informed of nutritional alternatives to HRT, which are currently still under investigation, and
other related current issues.3, 4